YOGA TEACHER CERTIFICATION

REGISTRATION FORM

 

Please print the following information and send with your $200 (US) deposit to:

DISCOVERY YOGA, 310 Boating Club Road, St. Augustine, FL 32084

 

Training Date (beginning)                                                                          

 

oMonth-long   oWeekends   oOther                                                           

 

 

 

 

 

ATTACH

PHOTO

HERE

 

 

 

 

 

Name:                                                                                                                                        Age:                     

 

Mailing Address:                                                                                                                                                    

 

                                                                                                                                                                                

 

Home Telephone: (      )                                                   Work Telephone: (      )                                                

 

Occupation  (If you're not currently employed, your vocation, training, or profession):

 

                                                                                                                                                                                

 

 

Are you currently taking yoga classes?     oNo     oYes                  How many times per week?                         

What tradition?                                                       How long have you been taking the class?                     

Comments:                                                                                                                                                        

                                                                                                                                                                           

                                                                                                                                                                           

 

 

Other relevant education and/or training (indicate type, level, length of training):

oKripalu                                                               

oIntegral                                                               

oIyengar                                                               

oSivananda                                                          

oAshtanga                                                           

oPhoenix Rising                                                   

oIntegrative Yoga Therapy                                 

o                                                                            

o                                                                            

o                                                                            

o                                                                            

o                                                                            

o                                                                            

o                                                                            

 

 

Are you currently teaching yoga?      oNo      oYes                         How many times per week?                         

               -week series          oOngoing class          oDrop-in class          oSubstitute

What tradition?                                                               How long have you been teaching?                        

Comments:                                                                                                                                                        

                                                                                                                                                                           

                                                                                                                                                                           

(Continued on other side)

Number of years practicing hatha yoga:           . How has your involvement changed and developed over time?  What does yoga means to you?                                                                                                                                        

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

 

 

Why did you chose Yoga Teacher Certification at this time in your life?                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

                                                                                                                                                                          

 

 

How did you find out about this Yoga Teacher Certification training?                                                             

                                                                                                                                                                          

 

 

HEALTH INFORMATION  Please indicate any conditions that apply to you.

oUnder medical treatment or supervision for:                                                                                                      

oPregnant: _____months at beginning of training.  Comments:                                                                         

oPrescription medications:                                                                                                                                     

oSerious illness, injury or major surgery within the last two years

    Conditions and dates:                                                                                                                                         

                                                                                                                                                                             

oPhysical  limitations:

                                                                                                                                                                                 

oDrug or alcohol dependency:                                                                                                                              

oCurrent psychotherapy, counseling or psychiatric treatment for:                                                                    

oHospitalization for psychiatric care within the last two years for:                                                                   

 

In case of emergency, please contact:

Name:                                                                                             Telephone:                                                   

Physician:                                                                                       Telephone:                                                   

Therapist:                                                                                       Telephone: